Plan Certificate

Complementary Care Rider

Federal law requires HMSA to provide you with this notice. HMSA complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. HMSA does not exclude people or treat them differently because of things like race, color, national origin, age, disability, or sex. Services that HMSA provides Provides aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats

(large print, audio, accessible electronic formats, other formats)

Provides language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages • If you need these services, please call

1 (800) 776-4672 toll-free; TTY 711 How to file a discrimination-related grievance or complaint If you believe that we’ve failed to provide these services or discriminated against you in some way, you can file a grievance in any of the following ways: • Phone: 1 (800) 776-4672 toll-free • TTY: 711 • Email:

Compliance_Ethics@hmsa.com • Fax: (808) 948-6414 on Oahu • Mail: 818 Keeaumoku St., Honolulu,

HI 96814 You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, in any of the following ways: • Online:

ocrportal.hhs.gov/ocr/portal/lobby.jsf • Phone: 1 (800) 368-1019 toll-free;

TDD users, call 1 (800) 537-7697 toll-free

• Mail: U.S. Department of Health and Human Services, 200 Independence Ave. S.W., Room 509F, HHH Building, Washington, DC 20201

For complaint forms, please go to hhs.gov/ocr/office/file/index.html. Hawaiian: E NĀNĀ MAI: Inā hoʻopuka ʻoe i ka ʻŌlelo Hawaiʻi, loaʻa ke kōkua manuahi iā ʻoe. E kelepona iā 1 (800) 776-4672. TTY 711. Bisaya: ATENSYON: Kung nagsulti ka og Cebuano, aduna kay magamit nga mga serbisyo sa tabang sa lengguwahe, nga walay bayad. Tawag sa 1 (800) 776-4672 nga walay toll. TTY 711. Chinese: 注意：如果您使用繁體

中文，您可以免費獲得語言援助

服務。請致電 1 (800) 776-4672。TTY 711. Ilocano: PAKDAAR: Nu saritaem ti Ilocano, ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Awagan ti 1 (800) 776-4672 toll-free. TTY 711. Japanese: 注意事項：日本語を話

される場合、無料の言語支援を

ご利用いただけます。 1 (800) 776-4672 をご利用くださ

い。TTY 711.まで、お電話にて

ご連絡ください.

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1 (800) 776-4672번으로 연락해 주시기 바랍 니다. TTY 711 번으로 전화해 주십시오.

Laotian: ກະລຸນາສັງເກດ: ຖ້າທ່ານເວົ ້ າພາສາລາວ, ການຊ່ວຍເຫຼື ອດ້ານພາສາ, ບໍ່ ມີ ຄ່າໃຊ້ຈ່າຍ, ແມ່ນມີ ໃຫ້ທ່ານ. ໂທ 1 (800) 776-4672 ຟຣີ . TTY 711.

Marshallese: LALE: Ñe kwōj kōnono Kajin Ṃajōḷ, kwomaroñ bōk jerbal in jipañ ilo kajin ṇe aṃ ejjeḷọk wōṇāān. Kaalọk 1 (800) 776-4672 tollfree, enaj ejjelok wonaan. TTY 711. Pohnpeian: Ma ke kin lokaian Pohnpei, ke kak ale sawas in sohte pweine. Kahlda nempe wet 1 (800) 776-4672. Me sohte kak rong call TTY 711. Samoan: MO LOU SILAFIA: Afai e te tautala Gagana fa'a Sāmoa, o loo iai auaunaga fesoasoan, e fai fua e leai se totogi, mo oe, Telefoni mai: 1 (800) 776-4672 e leai se totogi o lenei ‘au’aunaga. TTY 711. Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1 (800) 776-4672. TTY 711. Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1 (800) 776-4672 toll-free. TTY 711. Tongan: FAKATOKANGA’I: Kapau ‘oku ke Lea-Fakatonga, ko e kau tokoni fakatonu lea ‘oku nau fai atu ha tokoni ta’etotongi, pea teke lava ‘o ma’u ia. Telefoni mai 1 (800) 776-4672. TTY 711. Trukese: MEI AUCHEA: Ika iei foosun fonuomw: Foosun Chuuk, iwe en mei tongeni omw kopwe angei aninisin chiakku, ese kamo. Kori 1 (800) 776-4672, ese kamo. TTY 711. Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1 (800) 776-4672. TTY 711.

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HAWAI‘I MEDICAL SERVICE ASSOCIATION The Active&Fit® Program Benefit Rider

This Rider provides coverage that supplements the coverage provided in HMSA’s Guide to Benefits, which describes the benefits covered under your medical plan. Your coverage under this Rider starts and ends on the same dates as your medical plan coverage. All definitions, provisions, exclusions, and conditions of HMSA’s Guide to Benefits shall apply to this Rider.

You are eligible to receive the following benefits:

The Active&Fit Program – Covered

You and your covered dependents age 16 and older are eligible for either the Fitness Center program or Home Fitness program as described below. Talk to your doctor before you start or change your exercise routine. Fitness Center Program. Annual membership at a participating

Active&Fit fitness center or select YMCA. To find a list of participating fitness centers or YMCAs, visit the Active&Fit website or contact Active&Fit via the number listed on the last page of this Rider. You may request to change fitness centers once a month. The effective date of the change will be the first day of the month following Active&Fit’s receipt and processing of your request. Monthly fees may apply, depending on the fitness center tier you choose. You have access to a wide range of locations and services based on your budget and workout needs. Please note: Services and amenities may vary by fitness center location. For example, some fitness centers may offer saunas, swimming pools, whirlpools, dance, or yoga studios. You are responsible for the cost of additional services if the location charges a separate fee outside of the standard membership; or

Home Fitness Program. Select up to two (2) Home Fitness Kits per calendar year. Each kit may include a DVD, a guide, and/or other products. Your kit(s) will be shipped within 10 days of enrolling with Active&Fit and selecting the Home Fitness Program option. Availability of kits may change. Please contact Active&Fit to enroll, learn more about the contents of, and to select your kit(s). Contact information can be found on the last page of this Rider.

Choose from the following kits: 1. Aquatic Exercise Kit 2. Athletic Conditioning Kit 3. Barre Fitness for all Levels Kit 4. Barre Fitness Kit 5. Cardio Blast Kit 6. Cardio Pump Kit 7. Cardio Quick Fix Kit 8. Chair Aerobics Kit 9. Chair Boxing Kit 10. Chair Dancing Celebration Kit 11. Chair Dancing Kit 12. Chair Pilates Kit 13. Chair Tai Chi Kit 14. Chair Yoga Kit 15. Circuit Burn Kit 16. Diabetes Workout Kit 17. Exercises for the Bedridden and Physically Challenged Kit

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18. Exercise Kit 19. Fitbit Connected! Kit 20. High Energy Cardio Kit 21. High Intensity Bootcamp Kit 22. Lean Body Circuits Kit 23. Pilates Kit 24. Strength and Stamina Kit 25. Stress Management Kit 26. Tai Chi Kit 27. Tai Chi for Balance Kit 28. Total Body Workout Kit 29. Upper and Lower Body Workouts Kit 30. Walking Kit 31. Yoga Kit 32. Your Best Body Kit

For ages 18 and older when enrolled in either the Fitness Center or the Home Fitness program, the following online tools are also available at www.ActiveandFit.com: The Active&Fit Connected!™ tool is a fun and easy way to track

your exercise at a fitness center or through a wearable fitness device, app, or exercise equipment. Please note: You are responsible for the cost of purchasing additional apps, wearable fitness devices, or exercise equipment. Your use of the Active&Fit Connected! tool serves as your consent for American Specialty Health Fitness, Inc. to receive information about your tracked activity.

An online newsletter 4 times a year. Other web tools like a fitness center/YMCA search, online classes,

and more.

Your Payment Obligations Annual Deductible Your annual deductible does not apply to the Active&Fit Fitness

Center Program or Home Fitness program.

Annual Member Fee Fitness Center Program. $75 Annual Member Fee.

Enroll with and pay your Annual Member Fee directly online at www.ActiveandFit.com or call Active&Fit at the number listed on the last page of this Rider; or

Fitness Center Buy-Up Option. We have expanded our Active&Fit program in Hawaii to include a wider range of fitness centers to meet your workout needs. Based on the buy-up fitness center you choose, a monthly member fee of $50, $70, or $100 will apply. Your credit card will be charged monthly based on your choice. Log in to www.ActiveandFit.com to see the options in your area.

Home Fitness Program. $10 Annual Member Fee. Pay your Annual Member Fee directly online at www.ActiveandFit.com or call Active&Fit Customer Service and select your kit(s).

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Please note: the following applies to the Annual Member Fee: The Annual Member Fee cannot be refunded. The Annual Member Fee is required each calendar year renewal.

Annual Copayment Maximum Annual member fees for the Fitness Center or Home Fitness

program do not apply toward meeting the Annual Copayment Maximum.

Services Not Covered The following services are not covered: Services or supplies provided by any person, company, or provider

other than a participating Active&Fit fitness center. All education materials other than those produced for the Active&Fit

program by American Specialty Health Incorporated. Telecommunications devices, telephone handset amplifiers,

television recorders, and telephones compatible with hearing aids; vision support devices.

Program services or products for individuals other than the Active&Fit member.

All listening devices including, but not limited to, audiotape and CD players.

Services for members with serious medical conditions for which Active&Fit services are not appropriate.

Fitness devices and applications that require a fee are not reimbursed by the Active&Fit program.

Prescription drugs, over-the-counter products, dietary supplements, herbal supplements, vitamins, minerals, weight control or tobacco cessation products, meal-replacement beverages or powders, or any other type of food or food product, whether or not it is recommended, prescribed or supplied by a health care provider, fitness center, or program.

Definition Calendar year means the period beginning on January 1 and ending on December 1 of any year.

Contact Information The Active&Fit Program

Phone: 1-888-354-4934, Monday through Friday, 8 a.m. to 5 p.m. Hawaii Time

Website: www.ActiveandFit.com The Active&Fit program is provided by American Specialty Health Fitness, Inc. (ASH Fitness), a subsidiary of American Specialty Health Incorporated (ASH). Active&Fit and Active&Fit Connected! are trademarks of ASH and used with permission herein.

(00) 4000-109110 6.19 LE

Serving youMeet with knowledgeable, experienced health plan advisers. We’ll answer questions about your health plan, give you general health and well-being information, and more. Visit hmsa.com for directions.

HMSA Center @ Honolulu818 Keeaumoku St.Monday through Friday, 8 a.m.–5 p.m. | Saturday, 9 a.m.–2 p.m.

HMSA Center @ Pearl CityPearl City Gateway | 1132 Kuala St., Suite 400 Monday through Friday, 9 a.m.–6 p.m. | Saturday, 9 a.m.–2 p.m.

HMSA Center @ HiloWaiakea Center | 303A E. Makaala St. Monday through Friday, 9 a.m.–6 p.m. | Saturday, 9 a.m.–2 p.m.

HMSA Center @ KahuluiPuunene Shopping Center | 70 Hookele St.Monday through Friday, 9 a.m.–6 p.m. | Saturday, 9 a.m.–2 p.m.

Customer Relations representatives are also available in person at our Neighbor Island offices, Monday through Friday, 8 a.m. to 4 p.m.:

Kailua-Kona, Hawaii Island 75-1029 Henry St., Suite 301 | Phone: 329-5291

Lihue 4366 Kukui Grove St., Suite 103 | Phone: 245-3393

Contact HMSA. We’re here for you.

Call 948-6111 on Oahu or 1 (800) 776-4672 toll-free on the Neighbor Islands or Mainland.

Together, we improve the lives of our members and the health of Hawaii. Caring for our families, friends, and neighbors is our privilege.

hmsa.com myhmsa @askHMSA askhmsa